Cultural representations of Infant Mental Health within two WAIMH publications: The Signal and Perspectives in Infant Mental Health (1993-2021)

This article focuses on a selection of papers, published by the World Association for Infant Mental Health (WAIMH), in The Signal (1993–2011) and Perspectives in Infant Mental Health (2012 to current) that directly address issues of culture within infant mental health (IMH) research, assessment, and intervention. This article forms part of a forthcoming WAIMH ebook publication; a sequel to Global Perspectives on the Transdisciplinary Field of Infant Mental Health 1993 – 2021: WAIMH eBooks Topical Resource Guide, Volume 1, (Keren et al., 2022).

Cultural expressions of parenting and the caregiving of infants and young children occur within culturally sensitive contexts that inform, protecting, caring for, and socializing children to optimally function in the world the parents perceive that they will grow up in (Bornstein, 2012; Bornstein et al., 2012; Bornstein & Lansford, 2010; Harkness et al., 2007). Similarly, infant mental health (IMH) as a field has highlighted the interconnectedness between cultural and relational experiences of parenting and caregiving, across generations (Fitzgerald et al., 2009; Spicer, 2011; Seymour St. John et al., 2013). Tronick (2007) states that,

…  culture helps define those features of the child’s behavior and communication that require attention and response, as well as the culturally appropriate form of the response. (p. 99)

What follows is a summary of selected papers, published by WAIMH in The Signal and Perspectives in Infant Mental Health (herein referred to as Perspectives), between 1993 and 2021, that explore the following themes:

  1. IMH within cultural contexts,
  2. IMH in humanitarian settings, and
  3. Headlining culture within infant mental health interventions and services.

The paper concludes with reflective questions. The questions invite us each to consider how we can grow together, beyond a single story or narrative about culture in IMH. They are an invitation to strive to listen to a rich complete narrative of each baby, in their family and their community, while also being awake to our personally and professionally culturally shaped and dynamic IMH narratives.

Culture in context matters

Miri Keren (Israel)

Keren, M. (2009). Editors Perspective: Is culture really taken into consideration in our tools for assessment and intervention, The Signal, 17 (4), 9.

In this paper, Keren highlights the importance of attending to culture as an integral part of any IMH intervention and this involves not only being curious and cognizant of the culture of the infant and families we are working with, but also of our own culture, and that which is embedded within of our IMH discipline.

… while we assess parent-infant interactions, we must know what is the profile of the best-fitted individual to the specific cultural group they belong to: the interactions of mother and infant can be seen as uniquely suited to the cultural goals and expectations. Overlooking it may lead to false diagnoses and irrelevant interventions. (Keren, 2009, p. 9)

In this brief salient paper, Keren provides a plethora of examples, with a focus on attachment behaviors across cultural settings.

Specifically relating to attachment behaviors across cultures, the Efe people (in the Ituri rainforest in Congo) have adopted a strategy that mitigates against risk of infant’s survival, as well as against loss of parents, in the form of multiple nursing and caregiving. This practice enhances the infant’s ability to form trusting relationships with a variety of individuals and probably impacts on the infant’s and adult caregivers’ brains. The Efe infant will show attachment behaviors to any individual in the group when distressed, as opposed to the Western infant who is expected to turn only to their immediate caregiver. (Keren, 2009, p. 9)

Connie Lillas and Mary Ann Marchel (USA)

Lillas, C., & Marchel, M. A. (2015). Moving away from WEIRD: Systems-based shifts in research, diagnosis, and clinical practice, Perspectives in Infant Mental Health, 23 (1-2), 10 – 15.

This paper examines trends in research regarding diversity and observes a parallel process within the field of IMH.  Drawing on the work of Henrich et al. (2010), the paper explores mismatches between research, diagnostic matters, and the families met in the day-to-day context of practice. Lillas and Marchel (2015) state,

As we explore the mismatches between current research and diagnostic approaches and their incongruence with the “real (clinical) world,” we hope to demonstrate that outside of the field of IMH, there is a more recent push to move from the simple to the complex, from the linear to the nonlinear, from the categorical to the dimensional, from the laboratory (isolated) to the community (collaborative) –all embedded within a dynamic systems framework. (p. 11)

This paper explores these emerging shifts in light of the emerging body of evidence-based treatments (EBTs) and concludes with a set of recommendations that remain salient within the IMH field.

  1. Be a responsible consumer of EBTs; notice the exact population, setting, and types of providers offering the EBT.
  2. Become an advocate for families in communities being offered EBTs that have evolved from subclinical mismatches and disparities.
  3. Even with EBTs targeted to actual high-risk clinic populations, not all were found to be superior in outcomes to “usual care” being offered. Do not disregard “usual care” as an anomaly but include it in an expanded database and treat it with respect and as part of the informed choice families have (Weisz & Gray, 2008).
  4. Support community-based orientations in research. Get involved on a ground floor level as a practitioner working in a community setting, working with real-world families that have multiple problems and co-morbidities.
  5. Use frameworks that hold multiple causalities, cut across diagnostic categories, and shed light on underlying neurodevelopmental processes and dimensions.
  6. Accept the challenge to work across silos. Move away from disciplinary fragmentation into interdisciplinary work –whether on an academic, research, or clinical level. (Lillas & Marchel, 2015, p. 14)

Suzanne Gaskins (USA) and Heidi Keller (Germany/Israel)

Gaskins, S., & Keller, H. (2019). Learning about children by listening to others and thinking about ourselves. Perspectives in Infant Mental Health, 27 (2), 1-4.

This editorial by Suzanne Gaskins and Heidi Keller was written in response to the Presidential Address by Kai von Klitzing (WAIMH President) published in the previous issue of Perspectives: WAIMH’s infants’ rights statement—a culturally monocentric claim? (von Klitzing, 2019).

Overall, von Klitzing (2019) recommends that instead of cultural relativistic attitudes towards infants, we would be better to “employ as much cultural sensitivity as possible when we implement them in the real social and cultural contexts”.

Gaskins and Keller (2019) stated, “… who should decide what is best for children growing up in a culturally specific context when these two sets of commitments conflict?” (p. 2). They encouraged WAIMH to continue with its commitment to inter-disciplinary dialogue regarding culture and IMH. In addition, they challenged the notion of universal pathways for child development and stated,

We fully agree that infants need reliable and emotionally responsive care from continuous caregivers. Our concern is that often a culturally specific model of who is the best caregiver and what is “sensitive care” is used to judge caregiver practices in other cultures. (Gaskins & Keller, 2019, p. 2)

Gaskins and Keller (2019) also challenged WAIMH to continue to be committed to inter-disciplinary dialogue:

We believe that any group trying to help children should be committed to the principle of “First, do no harm.” To this end, there is an urgent need to include anthropologists, sociologists, and cultural psychologists of childhood when formulating policies and interventions, to ensure that whole cultural systems that shape children’s lives are considered, not just isolated behaviors taken out of context. (Gaskins & Keller, 2019, p. 4)

For those who wish to further explore the work of Gaskins and Keller (2017), the following resource: Heidi Keller and Kim Bard (Eds.) (2017), The Cultural Nature of Attachment: Contextualizing Relationships and Development, Strüngmann Forum, Cambridge: The MIT Press. This edited text presents “multidisciplinary perspectives on the cultural and evolutionary foundations of children’s attachment relationships and on the consequences for education, counseling, and policy” (

IMH in humanitarian settings

Joshua Sparrow (USA)

Sparrow, J. (2017). Introductory remarks by Joshua Sparrow. Perspectives in Infant Mental Health, 25 (3-4), 9.

In this brief commentary, Joshua Sparrow introduces the Perspectives paper below by Mayssa El Husseini, Leyla Akoury-Dirani, Rami Elhusseini, and Marie Rose Moro (2017). Sparrow draws attention to the cultural awareness and inclusion of El Husseini and colleagues (2017) as they reflect on IECMH practice in Haiti, following the 2010 earthquake and ensuing cholera epidemic. Echoing and elaborating on Keren (2009), Sparrow reflects,

When infant mental health workers attempt to repair the disruptions of family ecosystems caused by natural or human-made disasters in cultures different from their own, they often bring interventions from their own cultures, along with the unexamined belief systems and cultural constructs that underlie them. Their understanding of those of the cultures they intend to work in are often understandably limited. Their interactions with those they intend to serve are also often marked by the trajectory of colonization and decolonization. (Sparrow, 2017, p. 9)

Mayssa El Husseini, Leyla Akoury-Dirani, Rami Elhusseini, and Marie Rose Moro (Husseini and Moro, France; Akoury-Dirani and Elhusseini, Lebanon).

El Husseini, M., Akoury-Dirani, L., Elhusseini, R., & Moro, M. R. (2017). Considering cultural practices within a psychoeducational community support service for mother-infant health care: Field report. Perspectives in Infant Mental Health, 25 (3-4), 9-13.

This paper provides a reflection from french interventionists working in Haiti, following the 2010 earthquake where over 230,000 people died and 220,000 people were injured. This disaster was followed by a cholera epidemic, that occurred a few months after the earthquake. The authors stress the importance of holding local belief systems at the centre of all interventions. The paper specifically provides a qualitative narrative concerning infants and parents and their experiences of devastating loss, trauma, and the impact of this on the mental well-being and the feeding relationship. El Husseini et al. (2017) “reaffirm the legitimacy of cultural knowledge” (p. 12), as a foundation stone for new understandings that in turn inform interventions.

This paper presents illustrations of the work of international NGOs with Haitian caregivers and young children following significant humanitarian crises. At the same time, it raises important social and cultural questions about the interface of Euro-American practices within the cultural fabric of the Haitian community. It is not an exhaustive study of the humanitarian interventions and their impact on the Haitians’ cultural beliefs, but illustrates some of the barriers and also possibilities to effective intervention when there are social and cultural differences between those providing the services and those receiving them. (El Husseini et al., 2017, p. 9)

El Husseini et al. (2017) vividly describe what they describe as “ruptures in the cultural dimension” (p. 12). They provide a narrative that further describes this phenomenon:

Collective crises and potential traumas may create a rupture in the continuity of the cultural transmission, This includes the massive intervention of NGOs and their disruption of the long-established harmony between Euro-American medicine and traditional Haitian culture that Haitian society had evolved. This resulted in a defect in the cultural envelope that protects collective representations. When traditional and internalized collective convictions are shaken, a door to doubt and confusion is opened. The new transmissions that the NGOs dispense penetrate these openings and act as external objects that are difficult to integrate. (El Husseini et al., 2017, p. 12)

The paper is rich in ethnographic details and shows how unintentional contradictory messages were conveyed to mothers during psychological interventions in the humanitarian context. The authors call for local social and cultural dimensions to be central to any intervention and “reaffirm the legitimacy of cultural knowledge” (El Husseini et al., 2017, p. 12). They further state that “… to ensure adequacy and efficacy of their services, the International NGOs need to include an ethnological perspective while applying psychosocial interventions (El Husseini et al., 2017, p. 13).

Other examples that specifically highlight infant mental health within local cultural contexts and humanitarian settings are noted in Box 1.

Box 1. Examples of IMH and cultural context within humanitarian settings.

Zanon, O., Ius, M., & Milano, P. (2016). An immigrant family’s story. A shared care plan for early childhood development: A partnership experience between families, early childhood services, social and health services. Perspectives in Infant Mental Health, 24(4), 5-10. An Immigrant Family’s Story. A Shared Care Plan for Early Childhood Development: A Partnership Experience between Families, Early Childhood Services, Social and Health Services – Perspectives (

Romano, H., Baubet, T., Marichez, H., Chollet-Xémard, C., Marty, J. & Moro, M. R. (2011). Medical and psychological airport reception and care of children from Haiti adopted in France. The Signal,19(1),14-16.

Moro, M. R. (1994). Psychiatric interventions in crisis situations: Working in former Yugoslavia. The Signal, 2 (1), 1 -6  Scan_6-28-2019_15-28-54_1.pdf (

Rygaard, N. P. (2015). Infant mental health in the global village. An invitation to reader’s debate: Emerging infant environments, and future research. Perspectives in Infant Mental Health, 23(1-2), 3- 7.  INFANT MENTAL HEALTH IN THE GLOBAL VILLAGE. An invitation to reader’s debate: Emerging infant environments, and future research. – Perspectives (

Murray Harrison, A. (2014). “Los Momentos Magicos”: A practical model for child mental health professionals to volunteer by supporting caregivers in institutions in developing countries. Perspectives in Infant Mental Health, 22 (2),10.. “Los Momentos Magicos”: A Practical Model for Child Mental Health Professionals to Volunteer by Supporting Caregivers in Institutions in Developing Countries – Perspectives ( 

Headlining culture within infant mental health interventions and services

Culture is significant in research and practice yet over-represented by “Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies” (Henrich et al., 2010). For example, in Henrich et al.’s (2010) review of the subjects in behavioral science data, subjects from WEIRD societies were identified as the dominant subjects with findings assumed to have relevance across all cultures and cultural groups. However, the majority of infants live in societies recognised as low-middle-income countries and as such, are well-under-represented across global health and wellbeing research (Black et al., 2017; Lu et al., 2020).

WAIMH is an international organization and throughout The Signal and Perspectives, there is a plethora of papers that address in part, the issue of culture within infant mental health interventions and services. A sample of these papers is represented in Box 2.

Box 2. Examples of papers in The Signal and Perspectives that headline culture within infant mental health interventions and services.

Abatzoglou, G. (2011). Meeting infants and staff at the foundling home: Introducing concepts of transference and countertransference in an institutional context. The Signal, 19(1),10-12. Meeting infants and staff at the foundling home: Introducing concepts of transference and countertransference in an institutional context – Perspectives (

Berg, A. (2020). Diversity and the positive impact of culture and supporting families in context. A view from Africa, Perspectives in Infant Mental Health, 28(1),33-36.

Brown, K. A., Brown, C., & Berg, A. (2016). A parent group initiative intensive care unit South Africa. Perspectives in Infant Mental Health, 24 (1-2),16-20.

Dube, T. (2014). A Community Service Clinical Psychologist Reflects on a Parenting Skills Workshop in Nolungile Clinic in Khayelitsha, Cape Town. Perspectives in Infant Mental Health, 22(1),5-6. A Community Service Clinical Psychilogist Reflects on a Parenting Skills Workshop in Nolungile Clinic in Khayelitsha, Cape Town – Perspectives (

Fitzgerald, H. E. (2020). Celebrating Hiram Fitzgerald: Forty years with infant mental health. Perspectives in Infant Mental Health, 28(1),11-16.

Gonzalez-Mena, J & Briley, L. (2011). Improving infant mental health in orphanages: A goal worth considering. The Signal, 19(4),14-16. Improving infant mental health in orphanages: A goal worth considering – Perspectives (

Lopez, M. E., Shabazian A. N. & Spencer, K. A. (2013). Orphanage improvement. An important child protection discussion. Perspectives in Infant Mental Health, 21(4),7-12.

Martinez, B. Webb, M., Rodas, P., Gonzalez, A., Grazioso, M. & Rohloff, P. (2016). Field report: Early child development in rural Guatemala. Perspectives in Infant Mental Health, 24(1-2),6-8. field-report-early-child-development-rural-guatemala/

Peers, R., & Frost, K. (2013). The Ububele Baby Mat Project: a brief and cost-effective community-based parent-infant intervention. Perspectives in Infant Mental Health, 21(3),5-9. The Ububele Baby Mat Project: A Bried and Cost-Effective Community-Based Parent-Infant Intervention – Perspectives (

Puura, K., & Berg, A. (2018). Integrating infant mental health at primary health care level. Perspectives in Infant Mental Health, 26(2-3),4 – 7.

Reams, R. & Light, P. (2019). Going the distance: promoting rural participation in the professional development of infant mental health workers. Perspectives in Infant Mental Health, 27(3),28-30.

Salaka, S. (2011). Reaching out to young parents through the media – Keeping up with the (contemporary) times. The Signal, 19(1),9.  Reaching out to young parents through the media – Keeping up with the (contemporary) times – Perspectives (

Sebre, S. & Skreitule-Pikse, I. (2011). Attachment-based parent and preschool teacher training and research programs in Latvia. The Signal, 19(1),7-8.

Webb, M. F., Martinez, B., Rodas, P., Gonzalez, A., Rohloff, P. & del Pilar Grazioso, M. (2020). Language Interpretation in the administration of the Bayley Scales of Infant Development-III for an indigenous population in Guatemala. Perspectives in Infant Mental Health, 28(1),29-32.

Astrid Berg (South Africa)

Berg, A. (2012). When a little means a lot. The Signal, 20(2), 1- 5.

This paper reports on the development of infant mental health as a field of practice and research within South Africa. Berg (2012) eloquently threads and balances the expertise of local colleagues with those from abroad who collectively have contributed to the growth of IMH as a practice in South Africa.

Living and working in a country where there are not only enormous economic disparities, but also enormous cultural and language differences, we as mental health professionals face many challenges… One of the most profound challenges is that of meeting ‘the other’ – in essence it is the challenge of life: for the self to engage with an other – it is that on which our whole development is built … (Berg, 2012, p. 1).

Berg (2012) in acknowledging political and cultural change also reflects, “… have we truly dismantled and discarded our colonial attitude? Have we truly stopped to project our shadow, our inferior, disowned parts onto the racially ‘other’? Do we indeed realize that our world view is not shared by all?” (p. 2). In response to these reflective questions, Berg (2012) shares her experiences of working in Khayeltisha and working alongside a colleague who,

… knew about my patients’ beliefs, values and who could help me translate – not only from isiXhosa into English, and vice versa, but help me to get to know the culture in which my patients were embedded. This is more than understanding about poverty, or bridging language differences – it is about obtaining a deep knowing about another system of values and priorities where much is the same, but much is also different.  (Berg, 2012, p. 2)

The remainder of the paper is a treasure trove of lived experience and wisdom where Berg (2012) shares that “… often not that much is needed – a little can mean a lot – but that little has to be an attuned, mindful little” (p. 2). Berg shares specifically about the significance of a cultural mediator. A person who has lived experience and knowledge of the culture and world in which the mother has grown up and is currently living. The cultural mediator is a co-therapist. That is, to not literally translate the medical questions to the patient but to culturally translate and engage with the questions and the patient in a way that optimised the patient’s security and capacity to respond.

An example of this is provided by Berg:

Dr: Is she HIV?

CM: Can I ask something, are you

both well?

Pt: No I went for an HIV check and

they said I’m negative.

CM: when you were pregnant?

Pt: Yes they said I’m negative but

even though I have a baby I want

to check again

CM: Is it because you have a


Pt: No, but I don’t know

CM: What is it that you don’t


Pt: The other thing is I had TB when I was young. (Berg, 2012, p. 3)

Berg (2012) concludes with a reflective query for WAIMH.

… we cannot assume to know it all when other people have lived knowledge of a particular context. Let’s make links globally, let’s listen to each other and let’s put into practice what we say we believe, namely that the needs of human infants are the same, but that there are different ways of rearing infants –let’s get to know these, let’s respect them, but at the same time we need to tell the world what we are continually learning about the beginning of life. (p. 5)

Concluding reflection

While the overall content of The Signal and Perspectives reflects practice with infants within OECD countries, this paper highlights work across both publications that acknowledge and apprehend experiences of culture within multi-level contexts. All infant mental health research, assessment, treatment tools and modalities, are culturally embedded, though not always culturally articulated. However, there is a growing body of work within the field that is specifically addressing cultural sensitivity in practice. For example, Meurs et al. (2022) advocate for the interdisciplinary convergence of anthropology and psychology as a pathway to translating cultural sensitivity into practice.

As the field of infant mental health grows within an ever-evolving globalization of health context, it is acknowledged that more needs to be done to support local clinicians and researchers to tell the stories of infants and families in their communities and to share their expertise and practice wisdom with the global infant mental health community. Beginning with The Signal and carried forward to Perspectives, this publication remains committed to addressing cultures in context as part of its aim to promote and protect the mental health needs of all babies in their families in their communities.

Reflective questions: Beyond a single culture and IMH story

Culture shapes the world views of ourselves, in our families and communities and shapes both explicitly and implicitly our views on parenting infants and young children, and on “healthy” parent-child relationships. Culture is also dynamic. As such, it is worthwhile to frequently ask:

  1. How have my views and beliefs about parenting young children changed and developed?
  2. How has my capacity to listen and bring forth conversations of cultural beliefs and values developed over time?
  3. How has my openness and enquiry of the world views of colleagues, supported enriched team/collegial working relationships aimed at providing optimal IMH services/care?
  4. Does my workplace have an articulated cultural competence framework tailored specifically to working with families with infants and very young children?


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Bornstein, M. H. (2012). Cultural Approaches to Parenting. Parenting, science and practice12(2-3), 212–221.

Bornstein, M. H., Cote, L. R., Bakeman, R., Haynes, O. M., & Suwalsky, J. T. D. (2012). Modalities of infant—mother interaction in Japanese, Japanese American Immigrant, and European American dyads. Child Development, 83(6), 2073–2088.

Bornstein, M. H., & Lansford, J. E. (2010). Parenting. In M. H. Bornstein (Ed.), Handbook of cultural developmental science (pp. 259–277). Psychology Press.

Fitzgerald, H. E., Mann, T., Cabrera, N., Sarche, M., & Qi,n D. (2009). Development of infants and toddlers in ethnoracial families. Infant Mental Health Journal, 30(5), 425-432.

Harkness, S., Moscardino, U., Blom, M.J., Huitrón, B., Johnston, C.A., Sutherland, M.A., Axia, G., & Palacios, J. (2007). Cultural models and developmental agendas: implications for arousal and self-regulation in early infancy. Journal of Developmental Processes, 2, 5-29. 

Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people in the world? Behavioral and Brain Sciences, 33(2-3), 61-83. doi: 10.1017/ S0140525X0999152X

Keren, M., Foley, M., Weatherston, D. J., Puura, K., & O’Rourke, P. (Eds.) (2022). Global Perspectives on the Transdisciplinary Field of Infant Mental Health 1993 – 2021: WAIMH eBooks Topical Resource Guide, Volume 1. Finland: World Association for Infant Mental Health

Lu, C., Cuartas, J., Fink, G., McCoy, D., Liu, K., Li, Z., Daelmans, B., & Richter, L. (2020). Inequalities in early childhood care and development in low/ middle‐income countries: 2010–2018. BMJ Global Health, 5(2), e002314.

Meurs P, Lebiger-Vogel J, Rickmeyer C., & Jullian, G. (2022). Cultural Sensitivity in Preventive Infant Mental Health Care: An Example From the Developmental Guidance Project FIRST STEPS in Belgium. Front. Psychol. 13:831416. doi: 10.3389/fpsyg.2022.831416

Seymour St. John, M., Thomas, K., & Noroña, C. R., with the Irving Harris Foundation Professional Development Network Tenets Working Group (2013). ZERO TO THREE Corner. Diversity-Informed Infant Mental Health Tenets: Together in the struggle for social justice. Perspectives in Infant Mental Health, 21(2), 8-15.

Spicer, P. (2011). Culture and Infant Mental Health. Current Problems in Pediatric and Adolescent Health Care, 41(7), 188-191.

Tronick E. (2007). The neurobehavioral and social emotional development of infants and children. New York, WW. Norton & Company.

von Klitzing, K. (2019). Presidential Address: WAIMH’s infants’ rights statement—a culturally monocentric claim? Perspectives in Infant Mental Health, 27 (1), 1-4.

Weisz, J. R., & Gray, J. S. (2008). Evidence‐based psychotherapy for children and adolescents: Data from the present and a model for the future. Child and Adolescent Mental Health, 13(2), 54-65. Doi: 10.1111/j.1475-3588.2007.00475.x


Maree A Foley (Switzerland)